Simple Medical History Questionnaire

Please answer the following four questions truthfully. Explain any medications, conditions or injuries in the field box to the right.

Are you currently taking any medications?

Are you currently taking any medications?

Do you have any medical conditions that may preclude you from participating in rigorous physical activities?

Do you suffer from any diseases such as Diabetes, Liver, Lung, Heart or Kidney disease?

Do you have any physical conditions or previous injuries that may preclude you from participating in rigorous physical activities?

Release and Terms of Agreement

This release is entered into between the undersigned and ArmanEckelbarger/Pasco County IMPACT its officers, trainers, affiliates, trainers and any and all other private and public locations where fitness classes are held. The purpose of Pasco County IMPACT is to provide fitness instruction and coaching for various levels of athletes/individuals.
The undersigned hereby acknowledge that the following was explained to me and/or agree to the following:
1. Acknowledges that Arman Eckelbarger is not a physician and is not trained in any way to provide medical diagnosis, medical treatment, or any other type of medical advice.
2. Acknowledges that coaching/training is another tool for teaching athletes/individuals about themselves, but that Arman Eckelbarger/Pasco County IMPACT does not guarantee neither good nor bad will occur nor guarantees the training advice given by Arman Eckelbarger/Pasco County IMPACT will produce good nor bad results.
3. Acknowledges that the undersigned has been told if they feel tired, feel pain or feel out of the ordinary in any way either related to your training, or otherwise, that the undersigned should contact a physician at once.
4. Videography and photography may be taken at various class locations which may appear on TV, web video, print or any other digital format. When possible, the class participants will be told in advance of the days in which any photography or videography will be done. "Before & after" photos will not be used for any promotional purposes unless written authorization is granted.
5. Acknowledges that IMPACT, aerobic classes, martial arts, kick boxing, running, kung-fu, weight training, obstacle courses, and any other related sports are an extreme test of one's mental and physical limits and carry with it potential for damage or loss of property, serious injury and death. That the undersigned assumes the risks of participating in these types of events/activities including the inherent dangers of the natural elements, that they are fit, and they have a regular medical physician they can contact regarding any medical problems that they might develop. The undersigned expressly waive, release, discharge and agree not to sue from any liability of death, disability, personal injury, or action of any kind and Arman Eckelbarger/Pasco County IMPACT for the undersigned participating in said sporting events and/or training for said sporting events.
The Undersigned agrees that this is the full agreement between the parties, that Arman Eckelbarger/Pasco County IMPACT, nor anyone else has not verbally contradicted any of the terms of this release and that the undersigned has entered into this agreement free and voluntarily without force or coercion.

I commit to:

I promise to show up on time and not be tardy. If it happens, I am subject to 20 push-ups at the end of the session.

I promise to bring a great attitude and open mind towards achieving my goals.

I promise to bring a water bottle, towel, floor matt, appropriate clothing and footwear along with 1-2 sets of dumbells (light set & heavier set). Optional hat and sunglasses.